Nivolumab plus ipilimumab, pembrolizumab may be most cost-effective in advanced melanoma

Nivolumab plus ipilimumab- and pembrolizumab-based therapies may be the most cost-effective approaches in advanced melanoma, according to a study.

“The effectiveness of immune checkpoint inhibitors and BRAF and MEK inhibitors has improved advanced melanoma recovery,” Bin Wu, PhD, of the medical decision and economic group at Ren Ji Hospital and the department of pharmacy at Shanghai Jiao Tong University School of Medicine, Shanghai, China, and colleague wrote. “However, it is unknown whether these novel therapies are cost-effective for newly diagnosed advanced melanoma with unknown BRAF status.”

In the decision-analytic model, the researchers aimed to compare the cost utility of immune-checkpoint BRAF and MEK inhibitors with or without the guidance of BRAF gene testing.

The researchers obtained information for eight competing therapeutic strategies derived from the CheckMate 067, KEYNOTE-006, COMBI-d and COMBI-v trials. The U.S. payer perspective was used to estimate costs.

Cost, along with quality-adjusted life-years (QALYs), incremental cost-utility ratio and incremental net health benefits, served as the outcome measures of interest. The data set also included subgroup, one-way and probabilistic sensitivity analyses.

Results showed that nivolumab plus ipilimumab without patient selection based on BRAF testing was associated with the most significant health outcome. The findings also showed that nivolumab was “the cheapest option,” according to the researchers.

Other findings showed what the researchers called a “cost-effective frontier,” which included nivolumab, pembrolizumab and nivolumab plus ipilimumab.

The incremental cost-utility ratio per QALY for pembrolizumab vs. nivolumab was $8,593 (standard deviation = $592,995), according to the results. For the comparison between nivolumab plus ipilimumab and pembrolizumab, this was $125,593 (SD = $5,751,223).

In their assessment of cost-benefit ratio, the researchers defined a “dominated strategy” as one that is more costly yet less effective than an alternative. Moreover, an “extended dominated strategy” was one that had a higher incremental cost-utility ratio than the next most effective strategy.

With those parameters in mind, the other strategies that underwent investigation — including those that were guided by BRAF genetic testing — were all determined to be dominated or extended dominated.

The efficacy of novel regimens was ultimately found to be the most influential parameter in the analysis.

“For newly diagnosed advanced melanoma with unknown BRAF pathogenic variant status, nivolumab plus ipilimumab and pembrolizumab strategies are likely to be the most cost-effective options,” the researchers wrote. “BRAF and MEK inhibitors might be productively placed in a